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A case of conflicting paradigms: nursing and reproductive technology.

This article addresses the paradigm conflict between nursing and reproductive technology. This technology is discussed as a conceptual system emphasizing fragmentation and distance, in contrast to the philosophical foundation of nursing, which aspires to holism and connection. The sensory modalities of sight, the paradigmatic sense of distance, and touch, the paradigmatic sense of connection, are considered as they highlight the conflict between nursing and reproductive technology. Particular attention is given to the techniques of ultrasonography and amniocentesis.

Amniocentesis↗

[New reproductive technologies: oocyte donation. What could be new in this field?].

This article discusses the so-called "new" reproductive technologies. The author analyzes and challenges this adjective, since for over two decades this group of medical techniques and experiments has been widely disseminated in the medical market. The media's coverage of test tube babies, and especially developments in intervention on human germ cells and embryos, help challenge the supposed permanent novelty of everything surrounding reproductive technologies and genetic interventions. Society is doubtless experiencing an open process in full innovation, but the social and symbolic effects on planning maternity, paternity, and filiation are still not well perceived or discussed. To illustrate such contradictions, the article focuses on the case of oocyte donation, highlighting the need for new perspectives in terms of social control over the dissemination of reproductive technologies.

Bioethics↗

Reproductive technologies in developing countries.

Are there any ethical concerns about reproductive technologies that are specific or unique to developing countries? Three ethical concerns often mentioned specifically in regard to developing countries are (1), the "overpopulation argument"; (2) the limited resources argument; and (3) the ethical problem of poorly trained practitioners offering their services to unsuspecting and uninformed infertile individuals or couples. Each argument is explored in some detail, with the conclusion that ethical problems do, in fact, exist but are not unique to developing countries. Nevertheless, the difficulties relating to reproductive technologies are likely to be greater in developing countries than in developed ones because of limited resources and a larger number of poor people residing there.

Delivery of Health Care↗

Whose baby is it? The impact of reproductive technologies on kinship.

Birth is not merely a biological event; it is also a social event in that it creates relationships. As a consequence of reproductive technologies, the boundaries between the biological and social basis of kinship have become blurred. Reproductive technologies challenge previously held cultural constructions of kinship and bring about new kinds of social relations in that kinship boundaries are redefined. This paper discusses the societal effects that reproductive technologies have had in challenging previously held notions of parenthood, kinship and relatedness.

Family↗

Ethical considerations of the new reproductive technologies. Ethics Committee of The American Fertility Society.

In September 1986, The American Fertility Society issued a report, Ethical Considerations of the New Reproductive Technologies, setting forth the then-held ethical position of the Society on the various new reproductive technologies. In 1987, the Congregation for the Doctrine of the Faith issued the Instruction on the Respect for Human Life and Its Origin and on the Dignity of Procreation. While both documents state that very similar moral criteria were used to derive ethical positions with respect to various reproductive procedures, the conclusions as to the ethical acceptability of the various procedures differ sharply in the two documents. The question can be raised about the procedure used by the Congregation of the Faith to derive its conclusions from the stated premises. Thus, while stating that "the individual integrally and adequately considered" is to be the basis of the moral judgment, the fact is that most conclusions are based on and referenced to past Catholic statements. While the difference in conclusion from similar premises may be troubling to society, it can be especially paralyzing to four groups: (1) those who face problems that might be solved by one or another of the new reproductive technologies; (2) those who are involved in applying them; (3) those who are responsible for institutional policies where such techniques may be applied; and (4) those who are in a position to influence public policy in a legislative or regulatory way. Because of the conflicting conclusions of the two documents, the present Ethics Committee (1986-87) of The American Fertility Society was convened and considered these guidelines in the light of the Instruction. For reasons set forth previously, the Committee reaffirmed the finding of the 1985-86 Committee that basic in vitro fertilization with homologous gametes is ethically acceptable. The Committee reaffirmed the finding that the use of heterologous gametes is also ethically acceptable, provided that various precautions and guidelines are observed, as outlined in its previous report. The Committee recognized and re-evaluated the long-debated and very complex issue of the moral status of the gamete, zygote, pre-embryo, embryo, and fetus. The reasons for believing that progressive degrees of respect are due with progressive development were set forth here and in the previous document. The Committee reaffirmed the position that experimentation on the pre-embryo in conformity with the policies and guidelines, as previously expressed, can be ethically justifiable and, indeed, necessary, if the human condition is to be improved.(ABSTRACT TRUNCATED AT 400 WORDS)

Endocrinology↗

Son preference, sex selection, and the "new" new reproductive technologies.

Throughout recorded history, humans have tried to influence the sex of their offspring, through pregnancy injunctions, infanticide, and infant/child neglect. Reproductive technologies developed in the late 20th century allow determination of the sex of the offspring during pregnancy, making "sex selection" through abortion possible. Especially in parts of East and South Asia, sex selection against female fetuses has had dramatic consequences for male/female sex ratios. However, "newer" new reproductive technologies, such as prenatal genetic diagnosis and DNA-weighted semen selection, can now be applied for sex selection; eventually, the latter technology may become easily accessible as a noninvasive method. The prospects of these new technologies for sex selection must be considered in the light of cultural values surrounding son preference / daughter discrimination in many parts of the world, most notably Asia, as well as preferences for a "gender-balanced" family in much of the West. The ethical issues surrounding these technologies, such as the right to life and the equal treatment of female children, are potentially profound, but legislating the appropriate use of these "newest" new reproductive technologies will be difficult.

Asia↗

Reproductive technologies and court-ordered obstetrical interventions: the need for a feminist voice in nursing.

As the developments in and increasing use of reproductive technologies continue and as court-ordered obstetrical interventions occur, questions regarding nurses' roles in these developments become increasingly important. In this article, I identify a number of issues surrounding these developments in reproductive health care and examine how nurses have dealt with these issues. I also attempt to encourage nurses to examine and discuss these developments from a critical, woman-centered perspective. A review of articles from the nursing literature (1985-1990) grouped together on the basis of the concerns identified, approach used, or subjects studied is presented. The majority of researchers view reproductive technologies as either acceptable or as requiring legislation and control. Few researchers in nursing have identified concerns about reproductive technologies or court-ordered obstetrical interventions from a feminist perspective. It is crucial that questions be raised about the underlying assumptions of these measures and about their implications for women as patients and for nurses as practitioners, women, and promoters of health. Otherwise, nurses may be supporting technologies and other measures that harm women and nursing itself.

Female↗

Assisted reproductive technology: 25 years of progress.

Great strides have been made in assisted reproductive technology and nearly all forms of subfertility are now amenable to treatment. Constant advances in technology and ethical controversy ensure it has a high public profile. The impact of assisted reproductive technology will be discussed in this article.

Embryo Transfer↗

Trends in embryo-transfer practice and in outcomes of the use of assisted reproductive technology in the United States.

BACKGROUND: During the past decade in the United States, increasing attention has been paid to lowering the incidence of multiple gestations resulting from the use of assisted reproductive technology. To determine whether such efforts have been successful, we assessed national trends in embryo-transfer practice patterns and in outcomes after the use of assisted reproductive technology. METHODS: We analyzed data on outcomes of assisted reproductive technology procedures as reported to the Centers for Disease Control and Prevention from 1995 to 2001 by fertility clinics in the United States. We also analyzed data from the National Center for Health Statistics on the rates of twin births and triplet or higher-order multiple births. RESULTS: From 1995 to 2001 in the United States, the number of infertility clinics, the number of fresh-embryo cycles initiated, and the number of fresh-embryo transfers increased steadily. The average number of embryos transferred per cycle began decreasing in 1997, with the steepest decline (an 11.1 percent decrease) between 1998 and 1999. In contrast, the number of pregnancies and live births per cycle during the period from 1995 to 2001 steadily increased. Even though the percentage of pregnancies with twins did not change significantly between 1997 and 2001, the percentage of pregnancies with three or more fetuses significantly decreased every year, with the steepest decline (a 20.8 percent decrease) between 1998 and 1999, after the publication in 1998 of the American Society for Reproductive Medicine guidelines for embryo transfer. CONCLUSIONS: Since 1997 in the United States, there have been consistent decreases in both the number of embryos transferred per cycle and the percentage of pregnancies with three or more fetuses, as well as a consistent increase in the percentage of live births per cycle.

Adult↗

Assisted reproductive technology: the state of the ART.

At least one in ten couples of reproductive age is affected by infertility. Tubal disease, ovulatory defects, endometrosis and abnormal sperm physiology are the most common causes of failure to conceive. Many of these disorders can be treated successfully with surgery, ovulation induction or intrauterine insemination, but in selected cases, or where there is long-standing intractable infertility, assisted reproductive technology (ART) becomes the treatment of choice. We provide an overview of the techniques for assisted reproduction, including in vitro fertilization, gamete intrafallopian transfer and other related procedures. Indications for treatment, patient evaluation and advances in reproductive technology including embryo cryopreservation, micromanipulation and donor gametes are also reviewed.

Cryopreservation↗

Psychiatric issues related to infertility, reproductive technologies, and abortion.

Infertility, treatment with reproductive technologies, and abortion are among the most emotionally weighty and philosophically contentious experiences in most patients' lives. They involve the most intimate body parts and behaviors and the most heartfelt hopes and profound disappointments. They can strain relationships with partners, relatives, and friends. The primary care practitioner who is informed about the psychological impact of these experiences can play an essential role in interpreting medical information; helping patients think through their own values, resources, and options; facilitating communication between members of a couple and with their friends and family; providing emotional support; and identifying and treating psychiatric disorders that sometimes occur before, during, or after these experiences.

Abortion, Induced↗

Reasons for delaying childbearing--a survey of women aged over 35 years seeking assisted reproductive technology.

BACKGROUND: Many women seeking assisted reproductive technology for their first planned pregnancy may be unaware of the impact of age on fertility. METHOD: An anonymous mailed survey to women aged over 35 years with no previous planned pregnancies, registered with Monash IVF between January 2002 and May 2003. RESULTS: One hundred and fifty-two out of 266 surveys were completed (57%). The most common reported reasons for delaying pregnancies were: not having a partner (50%), wanting financial security (32%) and a career (19%) before having a family, only recently becoming interested in having children (26%), and being unaware of the impact of age on fertility (18%). DISCUSSION: Some reported reasons for delaying childbearing were beyond personal control. Lack of awareness of the impact of age on fertility may have contributed to the delay in a proportion of the women surveyed.

Adult↗

Infertility and bioethical issues of the new reproductive technologies.

The scientific breakthroughs resulting in the delivery of Louise Brown in 1978 have opened the floodgates for an ongoing bioethical discussion about medically assisted reproduction. The majority in our society has accepted in vitro fertilization as an ethically justifiable procedure for infertile couples. The concern persists, however, that new reproductive technology has started us on the course of a slippery slope with potentially dire consequences for the so-created children, the traditional family, and, indeed, for society as a whole. The moral status of the embryo is the central issue in debates about such reproductive developments as the "spare" embryo, embryo freezing, embryo donation, embryo research and micromanipulation. Conflicts of interests between the adult's desire to become a parent and the welfare of the offspring are at the root of moral objections raised against manipulation of human reproduction. Extracorporal conception with the possibility for various gamete donors has also brought the long-practiced procedure of artificial insemination by donor and the potential consequences for the child into the discussion. Surrogate mothering and surrogate gestational mothering force us to redefine the age old dictum mater certa est and can render the child a helpless pawn in parental, emotional, and legal strife. Over the ages, society has through firmly established values exerted control over reproduction and acceptance of the new member in the community. Sex without reproduction was a severe blow to the highly regarded societal belief in parenting as the epitomy of life goals. Reproduction without sex through various technically feasible collaborative means further jolts fundamental traditional values and mandates their re-evaluation. Ethical belief systems are by nature highly charged and fiercely defended. Thus, in a pluralistic society, a consensus on the question "What ought to be done of all that can be done with new reproductive technologies?" is probably unachievable. Heated controversies between interest groups constitute an additional psychological burden complicating the ethical ambiguities for some infertile couples who have to decide about using noncoital conception. The interdisciplinary group report by the ethics committee of the American Fertility Society published in the "Ethical Considerations of the New Reproductive Technologies" constitutes a wide framework of guidelines for rational consideration. It will, one hopes, help to formulate needed regulations because some segments of our society as well as many scientists and physicians in the field believe that not all that potentially can be done ought to be done.(ABSTRACT TRUNCATED AT 400 WORDS)

Ethics, Medical↗

Genomic imprinting and assisted reproductive technology: connections and potential risks.

Assisted reproductive technology (ART) has become the standard of care for the treatment of many types of infertility. As a result, the numbers of children born after ART worldwide has escalated dramatically, and attention has turned to the potential risks of these procedures to the health and development of the children. In addition to the well-established risks of multiple gestations, recent reports have suggested a link between ART and rare disorders of imprinting including Beckwith-Wiedemann syndrome and Angelman syndrome. Here we review molecular mechanisms of genomic imprinting, consider how ART procedures could influence imprinting of gametes and embryos, and review the reports connecting imprinting disorders to ART. We highlight the importance of long-term follow-up of children born after ART, and emphasize the need for an improved understanding of the mechanisms of imprinting at the molecular level so that methods to prevent disruption of this critical epigenetic process can be developed.

Angelman Syndrome↗

Screening practices and beliefs of assisted reproductive technology programs.

OBJECTIVE: To explore assisted reproductive technology (ART) programs' beliefs about and practices for screening program candidates for the use of ART services. DESIGN: An anonymous, self-administered, mailed questionnaire. SETTING: U.S. ART programs. PARTICIPANT(S): Directors of U.S. ART programs. MAIN OUTCOME MEASURE(S): Screening practices and beliefs, agreement with statements about screening rights and responsibility, information collected about candidates, and likelihood of turning away hypothetical candidates. RESULT(S): The majority of programs do not have a formal policy for screening candidates. The majority of program directors agree that they have a right and responsibility to screen candidates. On average, programs turn away 4% of candidates each year. The majority of programs report being very to extremely likely to deny treatment to the couples described in various scenarios, such as physical abuse, positive HIV status, and single parenthood. Significant variation was seen across programs in their likelihood of turning away various hypothetical candidates. CONCLUSION(S): There is substantial variation in ART programs' screening practices. These results highlight the need for increased debate over what constitutes inappropriate denial of access to services, and what are prudent, social, ethical, and medical judgments.

Female↗

Embryological strategies for overcoming recurrent assisted reproductive technology treatment failure.

In every assisted reproductive technology (ART) programme there are patients who experience repeated failure. If all laboratory and stimulation parameters are controlled, it is assumed that the underlying cause of failure is physiological, and is attributable to either of the gametes or the embryo. Within the laboratory, few tools are available, other than careful observation and embryo selection, to aid in selecting the right embryo to overcome this failure. The morphology of the zygote, the state of the cleaving embryos on day 2 and day 3 of development, and the blastocyst can influence implantation rates. However, without functional gametes it is unlikely that success can be achieved. An early indicator of this functionality is the morphology of the zygote, which can be influenced by either the oocyte or the spermatozoon, and can be altered by either improving oocyte quality during stimulation or by using donor sperm if the failure to conceive is attributable to the male gamete. Subsequently, selecting embryos for transfer on the basis of the morphology of zygotes and embryos at day 3 or day 5 of development with the addition of fragmentation scoring and assisted hatching has been found to overcome many cases of repetitive failure to conceive after ART.

Blastocyst↗

Assisted reproductive technologies in rhesus macaques.

The assisted reproductive technologies (ARTs) have been used in the production of rhesus monkey offspring at the Oregon National Primate Research Center (ONPRC) and that experience is summarized here. Additionally these technologies serve as a source of oocytes/embryos for monozygotic twinning, embryonic stem (ES) cell derivation and cloning. High fertilization efficiencies were realized with conventional insemination or following the use of intracytoplasmic sperm injection (ICSI) and approximately 50% of the resulting embryos grew in vitro to blastocysts. Both fresh and frozen sperm were employed in fertilization by ICSI and the resulting embryos could be low temperature stored for subsequent thawing and transfer when a synchronized recipient female was available or after shipment to another facility. Following the transfer of up to 3 embryos, an overall pregnancy rate of 30% was achieved with increasing rates dependent upon the number of embryos transferred. Singleton pregnancy outcomes following the transfer of ART produced embryos were similar to those observed in a control group of animals in the timed mated breeding colony at ONPRC. ICSI produced embryos were used in efforts to create monozygotic twins by blastomere separation or blastocyst splitting. While pregnancies were achieved following the transfer of demi-embryos, only one was a twin and it was lost to spontaneous abortion. ICSI produced embryos have also served as the source of blastocysts for the derivation of embryonic stem cells. These pluripotent cells hold potential for cell based therapies and we consider the monkey an important translational model in which to evaluate safety, efficacy and feasibility of regenerative medicine approaches based on the transplantation of stem cell-derived progeny. Finally, efforts to produce genetically-identical monkeys by nuclear transfer have been briefly summarized.

Animals↗

The prevalence of major congenital malformations during two periods of time, 1986-1994 and 1995-2002 in newborns conceived by assisted reproduction technology.

Evidence has emerged that assisted reproduction technology (ART) may be associated with an increased risk of congenital malformations, low birth weight, and genetic imprinting disorders. The aim of the study was to determine, the prevalence of major malformations in newborns conceived by standard in vitro fertilization (IVF) in 1986-1994 and newborns conceived by different types of ART procedures in 1995-2002. Data were collected from the IVF Registry and Israel Birth Defects Monitoring System for all infants (live births, stillbirths and terminations of pregnancy) delivered after 20 weeks' gestation who achieved a fetal weight of at least 500 g. The control groups consisted of all spontaneously conceived babies (live births, stillbirths and terminations of pregnancy) born in our center during the same time periods. During the first period, a total of 31,007 babies were born at our center, of whom 278 were conceived by standard IVF. Twenty-six of the IVF infants had major malformations, for a prevalence rate of 9.35%, which was 2.3-fold higher than that in the general population (4.05%). During the second period, 53,208 infants were born, of whom 1632 were conceived by ART. Major malformations were found in 147 ART infants, for a prevalence rate of 9.0%, which was 1.75-fold higher than in the general population (5.18%). Analysis of the clinical characteristics of the ART infants with major malformations showed that 70.3% were born preterm, 76.5% had low birth weight, 58.6 were twins, and 11.7% were triplets. The use of ART procedures increased by a factor of 3.4 in the second period. Two important outcomes of ART were observed: an increased prevalence of major malformations about double the general population in both periods, and a high frequency of adverse clinical characteristics among ART infants with major malformations. Infertile couples should be adequately counseled regarding the real risk of having a child with malformations or a preterm or low birth weight infant.

Congenital Abnormalities↗